CareFirst Careers

Lead Operations Functional Analyst

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Resp & Qualifications

Under the general supervision of a Supervisor or above the incumbent’s accountabilities may include, but are not limited to, the following:

1. Participates as the lead representative for the functional area in the implementation of new systems initiatives.  Defines, documents, and validate new business requirements with system requirements. Collaborates with Business Analyst staff in the creation and documentation of business process and workflow.  Actively participate in User Acceptance Testing, providing input to IT and ASU leadership, to ensure functional requirements were developed and work as required

2. Defines and documents the most complex business and system requirements and develops business work papers and specifications; reviews test results; determines if system handled claims as benefit contracts require; ensures that claims are correctly adjudicated as a result of systems fixes.

4. Conducts and leads the analysis of existing business processes and systems to determine human or technical errors.  Conducts research and documents recommendations, performs preparations for testing, update SOPs and training documents. Assures that all claims related to the error are corrected.

5. Performs status reporting and writing specifications for ad-hoc report requests.  Acts a project manager for sensitive providers/institutions projects or large-scale highly complex claims reprocessing projects resulting from an audit.  Expands knowledge and skills of CareFirst business processes, quality assurance, and system development methodology.

6. Provides ongoing internal and external customer support for system questions for customer inquiries Investigates and resolves sensitive, complex, and/or high priority customer service inquiries and complex appeals and problems impacting claims: serves as subject matter expert for business processes and related systems; coordinating with vendors and other parties as necessary, and tracks them to resolution; develops, documents, and communicates alternative workarounds for system defects until system solutions can be implemented.  

Required: This position requires a bachelor’s degree or equivalent work experience.  Must have been a Claims Processor II or above (substitute CSR II or above, Full Service CSR II or above, Adjustor II or above, Quality Assurance Analyst II, E&B Tech II or above) for a minimum of 6 years and/or have been in the Operations Functional Analyst/Healthcare System Analyst role for a minimum of 4+ years.

Demonstrated systems experience to include: FACETS and/or FLEXX and/or NASCO/and or CARE   experience. Thorough understanding of BCBS claims and service systems and reports is necessary.  Detailed knowledge of benefits packages, membership and claims systems.  Knowledge of administrative and internal procedures is essential, including internal/external  operating policies, business rules by product and platform, medical policy and BCBSA standards, MIA/VBOI regulations and governance, SAS70 and Sarbanes Oxley compliance.

Abilities/Skills: Relevant business and systems subject matter expertise.  Proven project management skills and experience working within the Software Development Life Cycle framework.  Experience in creating and documenting business processes and workflow. Ability to work independently and as part of a team. Excellent interpersonal skills demonstrating the ability to be an effective listener, negotiator and facilitator.  Ability to lead problem-solving discussions. Attention to detail and excellent analytical and problem-solving skills.  Excellent written and verbal communication skills and the ability to communicate with technical counterparts.  Excellent organizational skills and ability to set priorities and handle multiple projects concurrently.  Extensive PC skills including Microsoft office software such as Word and Excel. Must be able to effectively work  in a fast paced environment with frequently changing priorities, deadlines,  and  workloads that can be variable  for long periods of time.  Must be able to meet established deadlines and handle multiple customer service demands  from internal and external customers, within set expectations for service excellence.   Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

SOP writing experience. Experience with both mainframe and client/server technology.  Training experience.  Working experience with requirements analysis and software modeling tools


Department: IT & Business Support Contact Center

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 7/25/2018

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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